Identifying risk factors for imminent death in cancer patients with acute dyspnea

A substantial proportion of cancer patients presenting to an emergency cent er (EC) or clinic with acute dyspnea survives fewer than 2 weeks. If these patients could be identified at the the time of admission, physicians and p atients would have additional information on which to base decisions to con tinue therapy to extend life or to refocus treatment efforts on palliation and/or hospice care alone. The purpose of this study was to identify risk f actors for imminent death (survival less than or equal to 2 weeks) and shor t-term survival (1, 3, or 6 months) in cancer patients presenting to an EC with acute dyspnea and to combine these factors into a model to help clinic ians identify patients with short life expectancies. A random sample of 122 patients presenting to an EC with acute dyspnea was selected for a retrosp ective analysis. Data that were available to physicians during the initial EC visit included patient histories, triage and discharge vital signs, ches t radiographs, and laboratory results. These variables were used in univari ate and logistic regression models to develop predictive models for imminen t death and short-term survival. Variables and interactions meeting a univa riate criterion of P < 0.10 were included in stepwise regression by using f orward and backward stepping. Models were compared with the use of Hosmer-L emeshow statistics and receiver operating characteristics curves. Underlyin g cancers were 30% breast, 37% lung, and 34% other cancers. Triage respirat ion greater than 28/min., triage pulse greater than or equal to 110 bpm, un controlled progressive disease, and history of metastasis were found to be statistically significant predictors (<alpha> less than or equal to 0.05) o f imminent death. Patients with uncontrolled progressive disease had a rela tive risk of imminent death of 21.93. Relative risks for triage respiration , pulse, and metastases were 12.72, 4.92, and 3.85, respectively. Cancer di agnosis was not predictive of imminent death but was predictive when longer time periods were modeled. It may be possible to identify patients whose d eath is imminent from a group of cancer patients with acute dyspnea. Some f actors that predict imminent death (triage pulse and respiration) differ fr om those (cancer diagnosis) that predict short-term survival. Extent of dis ease/response to treatment is common to all models. These factors need furt her examination and validation. If these findings are confirmed, this quant ified information can help physicians in making difficult end-of-life decis ions. J Pain Symptom Manage 2000;20:318-325. (C) U.S. Cancer Pain Relief Co mmittee, 2000.